Professional Burnout and
Resilience
57 TH ANNUAL FAMILY
MEDICINE SEMINAR
JULY 31, 2014
TAOS, NEW MEXICO
DAMIAN BELLO, MD
[email protected]
Professional Burnout and
Resilience
MAINTAINING
HUMANITY, COMPASSION,
AND EXCELLENCE
IN AN EVER MORE
CHALLENGING
PRACTICE ENVIRONMENT.
 I feel emotionally drained from
my work
Yes
No
Sometimes
 I’ve become more callous towards
people since I took this job
 I feel I’m positively influencing
other people’s lives through my
work
Goals/Organization of talk
 Define Burnout
 Describe how it effects providers and patients
 Understand how burnout occurs
 Discuss how burnout is assessed
 Discuss ways to prevent burnout and treat it.
II. What is Burnout and
How Does it Occur?
Definition - Historical Perspective
 Merriam-Webster, “Burnout is the condition of
someone who has become physically and
emotionally tired after doing a difficult job for a
long time”
 1974 – Freudenberger, “The extinction of
motivation or incentive, especially where one's
devotion to a cause or relationship fails to produce
the desired results.”1
 1981 – Maslach & Jackson, Maslach Burnout
Inventory
1Fraudenberger
H. Burnout: The High Cost of High
Achievement - 1974
Professional Burnout Definition1
1.
Emotional Exhaustion - A chronic state of
physical and emotional fatigue resulting from
excessive professional and personal demands .
2. Depersonalization – A set of callous and
insensitive behaviors toward or feelings about one’s
patients, coworkers or even oneself .
3. Ineffectiveness - Decreased sense of personal
accomplishment.
1Maslach,
C., Jackson, S. E., & Leiter, M. P. (1996). The Maslach Burnout Inventory (MBI). Third edition,
Consulting Psychologists Press
How big is the problem?
 Half of all physicians report at least 1 symptom of
burnout1 and ⅓ – ½ of physicians meet burnout
criteria2
 ½ of medical students have symptoms of burnout
 The rate of burnout is increasing. 63% report more
burned out than three years ago3
1. Shanafelt, Arch Intern Med. 2012;172(18):1377-1385.
2. Dyrbye, JAMA. 2010;304(11):1173-1180. doi:10.1001/jama.2010.1318.
3. 2011 Cvejka survey
Symptoms of Burnout
Emotional Exhaustion
Depersonalization
Inefficacy
Loss of enthusiasm for
work
Cynicism/Sarcasm
Low sense of
accomplishment
Dread going to work
Feeling like the patient is
the problem
Feeling unproductive
Hard to get work day
started
Getting angry with
patients
Loss of job satisfaction
Fatigue
Irritability and moodiness Worries about getting
with co-workers & staff
fired or disciplined
Desire to work less, retire
early, or change careers
Results of burnout/Signs of Burnout
Emotional Exhaustion
Depersonalization
Inefficacy1
Decreased hours of work
Decreased patient
satisfaction/experience
Decreased job
performance
Early retirement or
resignation
Increased patient
complaints
Lower quality of work
Poor physical and mental
health
Increased medical errors
Decreased productivity
Lower Primary
Care Workforce
Lower Medicare
Reimbursement
Lower Quality*
1Shanafelt,
Dyrbye
American Family Physician 2013
Results of Burnout
 67% of physicians would leave medicine
today if they could4
 2/3 of Family Physicians would choose
medicine again, but only 1/3 would
choose family medicine5
1. Advisory Board
2.Medscape Physician Comp Report
2014
CGCAHPS
 The Clinician and Group Consumer Assessment of
Healthcare Providers and Systems
 Measures patient experience
 For large medical groups, reimbursement tied to
high scores (9-10)
 Examples



During your most recent visit, did this provider listen carefully
to you?
During your most recent visit, did this provider seem to know
the important information about your medical history?
During your most recent visit, did this provider spend enough
time with you?
Physician Wellness and Quality
 Reduced workplace productivity and efficiency
 Increased probability of ordering unnecessary tests
and procedures
 Burnout increased physicians self reported poor
quality of care
 Physician job satisfaction effects patient adherence
to treatment
 Burned out residents are 2-3x more likely to report
giving suboptimum care
1Wallace, Physician Wellness: a missing quality
Characteristics of Burnout
 Occurs more frequently than admitted both by
employers of physicians and by physicians
themselves
 Frequently ignored or accepted as part of doing
business
 There is an overriding rationalization of and
resistance to seeking and accepting help
More Characteristics
 Occurs on a continuum
 Not related to how hard or how much we are
working
 Tends to Occur in phases
 Women and men experience burnout differently
Response to stress – sex differences
Men
Women
 Emotional Exhaustion
 Depersonalization
 Depersonalization
 Emotional Exhaustion
 Lack of efficacy
 No sense of lack of
efficacy
How does Burnout Occur?
Stress
Stress
Stress
Burnout
Stress is normal, Burnout is not.
How
Burnout
Happens
Drummond – thehappymd.com
Burnout and Engagement
Burnout versus Engagement
 Exhaustion
 Energy
 Depersonalization
 Involvement
 Inefficacy
 Efficacy
“BURNGAGEMENT”
Burnout and Depression - Not the Same
Depression
Burnout
Effects are at work
Fatigue
Loss of job satisfaction
Feeling unproductive
Unable to get on top of
workload
6. Irritable with coworkers and patients
7. Hard to get work day
started
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
6.
7.
Effects all aspects of
life
Fatigue
Anhedonia
Low self esteem
Poor concentration and
memory at work and
home
Irritable with everyone
Hard to get anything
started
III. Causes and Risk Factors
The Perfect Storm
Professions with High Stress/Burnout
Education
Social Work
Real Estate
Health Professions
Job Stressors in High Burnout Professions
Air- traffic
controller
Life or
death
consequen
ces
x
Emotionally
charged
participants
Ethical
dilemmas
Physically
dependent
charges
Expectation
for
perfection
Hostage
negotiator
x
x
x
Judge
x
x
Motherhood
newborn
x
x
x
Healthcare
professional
x
x
x
x
x
High Burnout in Family Medicine1
1Shanafelt
Forms of stress
Physical
Emotional
Spiritual/Dissatisfiers
Physical Stressors
 Sheer amount of work1
 Extremes of activity2
 Poor self care - Lack of sleep3,4
 Demands outside work
 Illness or poor health
1Kimberly - Am J Public Health. 2003 April; 93(4)
2MayoClinic.org
3Miller - South Med J. 2000;93(10)
4Lancet 2009- Wallace
Emotional Stressors
 Constant expectation to empathize
 Helping people in crises is part of the job
 Social or geographic isolation
Spiritual Stressors
 Things that cause us to question
what we are doing and why. “Crisis
of Meaning”
 Inability to reconcile what we are
doing with what we want to do.
Self Determination Theory1
 Competence
 The need to feel valued as knowledgeable and skilled
 To experience mastery
 Relatedness
 The need to collaborate with colleagues and co-workers
 The need to interact, be connected to, and experience caring
for others
 Autonomy
 The need to exercise some control/influence to achieve
practice goals
 Sense of contribution to goal.
1Deci,
E., & Ryan, R. (1991). Nebraska symposium on motivation:
Vol. 38. Perspectives on motivation (pp. 237–288).
AMA Study1
 656 physicians, 30 practices, six states
 January 2013 through August 2013
 Key questions:
 What factors influence physician professional satisfaction
 What are the implications of these factors for patient care,
health systems, and health policy?
 Four Key findings
 Importance of delivering high-quality healthcare
 Pros and cons of electronic health records
 Value of stability and fairness
 Cumulative burden of regulations
1Friedberg - Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Santa
Monica, CA: RAND Corporation, 2013. http://www.rand.org/pubs/research_reports/RR439
EMR
The
Electronic
Medical
Record
 Positives

Legibility

Prescribing ease

Information Sharing
 Negatives

Physical stress: Increased work

Emotional stress: Barrier to Empathy

Spiritual stress:

Often does not improve the clarity of
documentation for clinical purposes

Sacrifices documenting to improve
patient care for coding and billing
The doctor patient relationship
 Changing with the times
 Pressure to see more patients
 Effected by remodeling of the health care system
 EMR
 Affected negatively by increased rates of burnout
 Patient satisfaction tied to reimbursement
 How important is it?
Mixed Messages/Competing Demands
Produce v. Take care of all pts needs
today
See patients v. Participate in
meetings
Produce v. Improve quality
Document well v. Document fast
Managing Multiple Expectations
 Patients
 Industry
 Ourselves
 The medical profession
 Our practice/employers
 Cultural
 Our families
Risk Factors for Burnout
 Incurs higher risk








Age <35
Middle stage of practice, 10-20 yrs post residency
Female > Male
Specialty, front lines of medicine
Adequate savings
Social or geographic isolation
Poor physical and mental health
Certain personality traits
 No risk association


Religious involvement was protective1 or not correlated2
Political Leanings2
Personality as a Risk Factor
 Personality Characteristics – innate, hard to change








Hardiness
Humility
Perfectionism
Introversion/extroversion
Workaholism
Type A
Compulsiveness
Optimism/pessimism
 Behaviors and preconceptions – acquired, easier to change






Charting habits
Taking on too much v saying “no”
Staying late v setting limits
Poor self care
Reluctance to take time off
Attitude and demeanor
 Values and their corruption1
1BO
and Resilience FPM article
IV. Assessing Burnout
Why is burnout so hard to address?
 For Providers - Culture of Medicine


Culture of Silence

Pressure to appear well as a sign of competence

Ethical dilemmas: collegial privacy v pt safety
Pluralistic Ignorance: A situation in which a majority of group members
privately reject a norm, but incorrectly assume that most others accept it,
and therefore go along with it.
 For Organizations

Lack of perceived value

Fear
1.
Burnout
I feel emotionally drained from
my work (Emotional
Exhaustion)
2. I’ve become more callous
towards people since I took this
job (Depersonalization)
3. I feel I’m positively influencing
other people’s lives through my
work (Personal
Accomplishment/Efficacy)
Maslach Burnout Inventory1
 MBI - 22 total questions
 9 on Emotional exhaustion - high is worse,
 5 on Depersonalization – high is worse
 8 on Personal Accomplishment – high is better
Scores are divided into high, moderate, and low
 aMBI - Abbreviated Maslach Inventory2
 9 questions – 3 in each area
 3 additional questions on “Satisfaction with Medicine”
1http://www.mindgarden.com/products/mbi.htm
2McManus
2003, British Medical Journal, 327, 139-142)
aMBI
abbreviated
Maslach
Burnout
Inventory
http://www.aagbi.org/sites/default/files/Maslach%20ScoringAbbreviated.pdf
Compassion Fatigue Assessment1,2
Invisible Signs
Visible Signs
Marked decline in work efficiency?
Intent on clinical tasks to the detriment
of patient interactions?
More callous toward patients than in
the past?
Signs of mental or physical breakdown
during crisis periods?
Outbursts of anger or irritability with
little provocation?
Declining opinion of caregiver role?
Treats patients like impersonal
objects?”
Developed a pressing desire to explore
an entirely different profession?
Repeatedly fails to fulfill clinical
responsibilities?
1.
2.
3.
4.
5.
6.
7.
8.
9.
1The
10.
11.
12.
13.
14.
15.
16.
17.
18.
Reduced sense of accomplishment
Harbor a secret happiness when a
procedure is cancelled?
Avoid interactions with patients and
colleagues when possible?
Often leave work feeling ineffective in
job?
Mood swings with every patient
interaction?
Resentment about role as caregiver?
Unhealthy attachment to patients?
Poor patient outcomes adversely affect
continued performance?
Anxiety when interacting with
emotional patients?
Advisory Board Company, Washington, DC
http://www.advisory.com/Talent-Development/Leader-Development/Members/Workshop-Resources/Operations/Hardwiring-Service-Excellence
2Pfifferling J, Overcoming Compassion Fatigue, Fam Pract Manag. 2000 Apr;7(4):39-44.
Informal Surveys
 Background
 The PMG Engagement Subcommittee - with input from
Lead Physicians - put together a one page survey, sent out
to all providers during the month of December, 2013.
 Questions – 5 point scale
 Does your work schedule allow you to maintain
appropriate work/life balance?
 Are the following staff in your clinic effective and helpful?
 Do you find yourself working past scheduled hours
 Results
Informal Self-Assessment1
 Have you become cynical or critical at work?
 Do you drag yourself to work and have trouble getting started







once you arrive?
Have you become irritable or impatient with coworkers,
customers or clients?
Do you lack the energy to be consistently productive?
Do you lack satisfaction from your achievements?
Do you feel disillusioned about your job?
Are you using food, drugs, or alcohol to feel better or just
simply not feel?
Have your sleep habits or appetite changed?
Are you troubled by unexplained headaches or other physical
complaints?
1Job
burnout: how to spot it and take action, Mayo Clinic.org
www.mayoclinic.org/healthy-living/adult-health/in/depth/burnout
The Burnout Continuum
Engagement
At Risk
Some
Burnout
Full
Burnout
V.
Treatment/Prevention/Resilien
ce
Who’s responsible?
 Individual Providers
 Organizations
 Medical schools
 Medical profession
 Government and policy makers
 Healthcare Industry
Happiness Research Analogy
 50% predetermined by genetics and family
 50% changeable
 10-38%
determined by recent event
 12-40%
under individual control
Lykken, Psychological Science Vol.7, No. 3, May 1996
Dual Responsibility
Individual
Organizational
The Burnout Continuum
Engagement
Some
Burnout
Full
Burnout
Where to Start?
Engaged
Some burnout
Full burnout
✓
Treat burnout
Decrease stress
✓
✓
Increase
resilience
✓
✓
Treating Burnout
 Take an Intentional Break*
 Take time to reflect on what is important to you
 Recall your personal values and why you went into
medicine
 Commit to 1-2 doable changes when you get back
 Interventions that have been shown to help
Participation in a discussion group
 Practicing mindfulness

*supported
by evidence
Benefits of Meditation
 Better Focus
 Less Anxiety1
 More Creativity
 Fosters Compassion1
 Better Memory
 Less Stress1
 More Grey Matter
1Ann
Fam Med September/October 2013 vol. 11 no. 5 412-420
What is this “Mindfulness”?
 A quality of the mind cultivated by meditating
where you train yourself to notice your
thoughts without judging them.
 “Mindfulness means paying attention in a
particular way, on purpose, in the present
moment, and non-judgmentally.”
-Jon Kabat-Zinn
 MBSR (Mindfulness Based Stress Reduction)
Strategies for Burnout

Downtime, rest, and rejuvenation


Improve personal health




Creative CME – audioCME, Smartbriefs
Work-Life balance, strengthen self-identity


Ask yourself pointed questions
Increase personal efficacy


Try to acknowledge staff and connect with colleagues every day
Get to know something personal about your patients
Gaining insight and self-reflection


Decrease workload, increase efficiency
Change your routine**
Improve relatedness/decrease isolation and depersonalization


Recommit to personal wellness
Stress reduction and increasing energy


Take a few 5-10 minute breaks throughout your day
Carve out time for friends and family
Increase autonomy, control

Reset the expectations of your patients
Change Your Routine
Still Stuck?
 Strategies List
 Resource List
Organizational Strategies
 Incorporate provider wellbeing into
organizational values and structure
 Prevention strategies should be:
 Thoughtful
 Practical
 Well-supported
in the organization
Provider Wellness Models
 Passive
 Open door policy
 Focusing on positive
 Reactive
 Critical incident stress debrief
 Suggesting outside counsel
Proactive
Well-being assessment
 Thoughtful, practical and supported prevention strategies

Organizational Strategies
 Promote Resiliency

Autonomy -

Relatedness –

Competence –
 Decrease Stress

Physical –

Emotional -

Spiritual –
Organizational Strategies
 Promote Resiliency

Autonomy - promote a culture of transparency and fairness

Relatedness –

Competence –
 Decrease Stress

Physical –

Emotional -

Spiritual –
Organizational Strategies
 Promote Resiliency

Autonomy - promote a culture of transparency and fairness

Relatedness – promote peer-peer interaction

Competence –
 Decrease Stress

Physical –

Emotional -

Spiritual –
Organizational Strategies
 Promote Resiliency

Autonomy - promote a culture of transparency and fairness

Relatedness – promote peer-peer interaction

Competence – improve support of CME (time and money)
 Decrease Stress

Physical –

Emotional -

Spiritual –
Organizational Strategies
 Promote Resiliency

Autonomy - promote a culture of transparency and fairness

Relatedness – promote peer-peer interaction

Competence – improve support of CME (time and money)
 Decrease Stress

Physical – decrease burden of regulations

Emotional -

Spiritual –
Organizational Strategies
 Promote Resiliency

Autonomy - promote a culture of transparency and fairness

Relatedness – promote peer-peer interaction

Competence – improve support of CME (time and money)
 Decrease Stress

Physical – decrease burden of regulations

Emotional - offer coaching or mindfulness courses

Spiritual –
Organizational Strategies
 Promote Resiliency

Autonomy - promote a culture of transparency and fairness

Relatedness – promote peer-peer interaction

Competence – improve support of CME (time and money)
 Decrease Stress

Physical – decrease burden of regulations

Emotional - offer coaching or mindfulness courses

Spiritual – Support Discussion Groups
Types of Discussion Groups
 Informal, unstructured groups
 Peer facilitated discussion groups
 Balint Groups
 Schwartz Center Rounds
Schwartz Center Rounds
 Demonstrated best practice
 Combats provider burnout and improves service
simultaneously
 Structure and design elements





Modeled after M&M rounds
Based on case presentations
Presentations proud discussions of underlying issues
Staff share best practices to address issues
Guided by a facilitator
Support Forums/Schwartz Center Rounds
 Key Attributes





Structured, regular forum for peer-to-peer support
Opportunity to work together on difficult interactions
Provision of framework to think through difficult patient situations
Opportunity to learn from others about how to manage stressors
Open discussion of emotions to help manage stress
 Common Pitfalls




Discussion times fall to the wayside overshadowed by other priorities
Culture prohibits sharing concerns
Devolves into a complaining session
No demonstrated learning change or alleviation of stress
Schwartz Center Rounds
 Supported by the Schwartz Center founded by Ken




Schwartz before he died of lung cancer in 1995
Nearly 300 hospitals and medical centers hold the
rounds
Open to all professionals with patient care
responsibilities
Help monthly 430 to 150 caregivers at no cost to the
hospital
Rounds first piloted at Mass General Hospital in
1997
Schwartz Center Video
 The Schwartz Center Story
 http://bcove.me/y5irjltl
More Research is Needed
 Further research is needed to explore how
interventions designed to improve provider wellness
are also beneficial to patients and the organizations
VI. Conclude and Closing
Thoughts
CALVIN AND HOBBES FEEDING DAD THE BUG
Questions
and
Comments
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